Adults with Atrial Septal Defects — Surgical or Transcatheter Closure?
Abstract & Commentary
Source: Kotowycz MA, et al. Long-term outcomes after surgical versus transcatheter closure of atrial septal defects in adults. JACC Cardiovasc Interv 2013;6:497-503.
Atrial septal defects (ASD) can lead to exercise intolerance, pulmonary hypertension, right heart failure, and reduced life expectancy if they are not repaired. Surgical closure for ASD transformed the care of these patients and resulted in similar life expectancy to subjects without ASD. In recent years, transcatheter ASD closure has largely replaced surgery, but long-term data comparing the two techniques are limited. Kotowycz and colleagues performed a retrospective study of all patients ages 18-75 years who had surgical or transcatheter ASD closure in Quebec, Canada. They searched the Quebec congenital heart disease database for physician claims and hospital discharge summaries and cross-referenced with the province death database. All patients with ASD receiving surgical or transcatheter closure were enrolled in the study. To ensure they only enrolled patients with secundum ASD, they excluded cases with codes for other congenital heart diseases and those with a stroke in the preceding year (as these could have been patent foramen ovale [PFO] closure cases). The Amplatzer Septal Occluder was used in all cases of transcatheter closure. Primary outcomes were 5-year repeat intervention and all-cause mortality. Secondary outcomes were short-term (1-year) onset of congestive heart failure, stroke, or transient ischemic attack, and markers of health service use.
Between 1988 and 2005, 718 ASD closures were performed; 383 were surgical and 335 were transcatheter. At baseline, patients undergoing transcatheter closure were older (49 vs 43 years, P < 0.001) and more likely to have systemic hypertension (32% vs 25%, P = 0.037), but were less likely to have pulmonary hypertension (7.6% vs 16.4%, P < 0.001). Five-year mortality with transcatheter closure was similar to surgical ASD closure (5.3% vs 6.3%, P = NS). At 5 years, reintervention was more likely in patients with transcatheter vs surgical ASD closure (7.9% vs 0.3%, P < 0.01), but the majority of these reinterventions occurred in the first year. Secondary outcomes were similar in the two groups: The rates of heart failure, stroke, and TIA were similar between groups — the surgical group had more outpatient visits and the transcatheter group had more echocardiograms. The authors describe a steady increase in the use of transcatheter closure, and a steady decline in surgical closure, after 1998 when transcatheter closure was introduced. Interestingly, when comparing only the cases from 1998 onward, there was a trend toward lower mortality in the transcatheter group. The authors conclude that transcatheter ASD closure is associated with a higher long-term reintervention rate, but a long-term mortality that is not inferior to surgery. Overall, these data support the current practice of using transcatheter ASD closure in the majority of eligible patients and the decision to intervene on ASD with significant shunts before symptoms become evident.
This study adds to the growing body of literature that both surgical and transcatheter closure of secundum ASD in adults are safe and effective in the long term. This study is a retrospective cohort study, not a prospective, randomized trial, so there is likely to be significant bias inherent in the allocation of patients to either group. Thus, conclusions should be made cautiously, taking into account the other literature that concerns ASD closure in adults. This study is consistent with the majority of such observational studies, which show similar success rates and benefits from transcatheter and surgical approaches to closing ASDs in adults. It is unlikely that large-scale, randomized, controlled trials will ever be completed comparing these techniques, so these types of studies are important in this field. It should be recognized that this study is based on administrative data and claims, so there may be inaccuracies in the coding information. Further, we are not told of antiplatelet and anticoagulation regimens used postoperatively, which may impact outcomes. Overall, however, this is one of the larger series examining surgical vs transcatheter ASD closure, and is thus important. How should we approach adults with secundum ASD in the light of these data? It is clear that secundum ASDs with large left-to-right shunts need to be closed, but there does not appear to be a single best option. The choice between transcatheter and surgical options should continue to be individualized to each patient, and both appear to be reasonable options in the long term.